Aniceto 

and da Silva Leandro 
Sports Medicine - Open (2022) 8:87
https://doi.org/10.1186/s40798-022-00475-2

CURRENT OPINION Open Access

Practical Blood Flow Restriction Training:

New Methodological Directions for Practice
and Research
Rodrigo Ramalho Aniceto*    and Leonardo da Silva Leandro 

Abstract 
Most studies with blood flow restriction (BFR) training have been conducted using devices capable of regulating the
restriction pressure, such as pneumatic cuffs. However, this may not be a viable option for the general population
who exercise in gyms, squares and sports centers. Thinking about this logic, practical blood flow restriction (pBFR)
training was created in 2009, suggesting the use of elastic knee wraps as an alternative to the traditional BFR, as it
is low cost, affordable and practical. However, unlike traditional BFR training which seems to present a consensus
regarding the prescription of BFR pressure based on arterial occlusion pressure (AOP), studies on pBFR training have
used different techniques to apply the pressure/tension exerted by the elastic wrap. Therefore, this Current Opinion
article aims to critically and chronologically examine the techniques used to prescribe the pressure exerted by the
elastic wrap during pBFR training. In summary, several techniques were found to apply the elastic wrap during pBFR
training, using the following as criteria: application by a single researcher; stretching of the elastic (absolute and
relative overlap of the elastic); the perceived tightness scale; and relative overlap of the elastic based on the circum-
ference of the limbs. Several studies have shown that limb circumference seems to be the greatest predictor of AOP.
Therefore, we reinforce that applying the pressure exerted by the elastic for pBFR training based on the circumference
of the limbs is an excellent, valid and safe technique.
Keywords:  KAATSU training, BFR, Restriction pressure, Prescription, Elastic wraps

Key Points about the individual’s safety and adherence to the

• The literature demonstrates that in most cases the
elastic wrap can replace the pneumatic cuff tradition-
ally used for BFR training.
• It is suggested to use 10–30% elastic restraint per-
centages based on the limb circumference at rest
for pBFR training, depending on the type of elastic,
experience and training objective, and also thinking
*Correspondence: rodrigo-afa@hotmail.com
Study and Research Group in Biomechanics and Psychophysiology
of Exercise, Department of Physical Education and Sport, Federal Institute
of Education, Science and Technology of Rio Grande do Norte, Rua Manoel
Lopes Filho, nº 773. Valfredo Galvão, Currais Novos, RN CEP: 59380‑000, Brazil
training program.
• Future studies should be conducted with pBFR com-
bined with exercise using different elastic wraps in
terms of material composition and architecture, as
well as applying this type of training to healthy (i.e.,
athletes) and clinical populations (i.e., obese, injured).
Introduction
Blood flow restriction (BFR) training is characterized by
using a relatively light and flexible wrap (i.e., pneumatic
cuff, elastic wraps) placed in the proximal region of the
upper or lower limbs in order to apply adequate pressure
to the limbs capable of restricting blood flow in the mus-
cle due to occlusion of venous blood flow and restricting

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Aniceto and da Silva Leandro Sports Medicine - Open (2022) 8:87
the arterial blood flow. This type of training has shown
an increase in muscle mass, strength and performance
in different populations when combined with strength
or aerobic training (e.g., older adults, athletes, injured
patients) [1–4].
Most studies with BFR training have been conducted
using devices capable of regulating the restriction pres-
sure, such as pneumatic cuffs. The researchers in the first
BFR training studies arbitrarily used restriction pres-
sures with fixed or progressive values for all subjects [4,
5]. Then afterward in considering individualized pres-
sure prescription, researchers began to use a hand-held
Doppler probe together with a pneumatic cuff to find
the arterial occlusion pressure (AOP) at rest (“maximum
pressure” = 100%) and then prescribed the BFR for physi-
cal training based on this value (i.e., 50% of the AOP) [6].
Even though knowing the amount of pressure in mmHg
applied to the limbs is very important, especially for clin-
ical and research environments, this may not be a viable
option for the general population who exercise in gyms,
squares and sports centers. Thinking about this logic,
Loenneke and Pujol [7] created the practical blood flow
restriction (pBFR) training in 2009, suggesting the use of
a 7.6-cm-wide elastic knee wrap (Harbinger Red-Line,
Fairfield, CA, USA) as an alternative to the traditional
BFR, as it is low cost, affordable and practical.
In this sense, several studies have investigated the
acute and chronic effects of pBFR training, but unlike
traditional BFR training which seems to present a con-
sensus regarding the prescription of BFR pressure based
on AOP, pBFR training studies have used different tech-
niques to apply the pressure/tension exerted by the elas-
tic wrap. Therefore, this Current Opinion article aims
to critically and chronologically examine the techniques
used to prescribe the pressure exerted by the elastic wrap
during pBFR training in an attempt to suggest a valid and
safe standard technique for pBFR training in a practical
and scientific context.
Prescription of pBFR Training: Focusing on Methodological
Aspects
After Loenneke and Pujol [7] suggested the application of
pBFR training, several studies started using pBFR com-
bined with resistance exercise [8, 9] and aerobic exercise
[10, 11] in different populations, for example with female
and male adults [8–12], and for injured athlete in need of
osteochondral fracture rehabilitation [13]. The first stud-
ies conducted with resistance exercise combined with
pBFR with continuous pressure, showed conflicting data.
In the study by Loenneke et  al. [8] perceived exertion
responses were significantly higher after the first and sec-
ond set of resistance exercise with pBFR when compared
to the same exercise protocol without BFR (control). In
Page 2 of 7
contrast, in the study by Loenneke et  al. [14] perceived
exertion responses were similar between pBFR and con-
trol. In both studies, the subjects performed bilateral leg
extensions with a load at 30% of 1RM until exhaustion.
These contradictory findings seem to demonstrate that
the pressure applied during pBFR training may not have
been sufficient to adequately restrict arterial blood flow,
probably due to the way the elastic bands were wrapped
around the limbs (see illustration in Loenneke and Pujol
[7]). Furthermore, it was observed that no robust criteria
were used for prescribing the elastic wrap (7.6 cm wide),
as it was only reported that the elastic wrap was placed by
the same investigator to maximize intra-rater reliability.
Additionally, in a study by Yamanaka et  al. in 2012
[15], pBFR training with resistance exercise induced an
increase in strength and limb girth in athletes. The elastic
wrap (5 cm wide) was pulled to overlap 5.08 cm in rela-
tion to the initial length of the elastic applied without
tension; thus, an arbitrary fixed prescription was used for
all individuals. This same technique was later used in sev-
eral studies [16–18]. It is important to highlight that the
aforementioned procedures of the studies [8–15] regard-
ing the prescription of pBFR pressure were performed
without knowing what effect was being caused on the
arterial and venous blood flow.
Considering this, in 2013, Wilson et  al. [19] sought to
validate pBFR using the same elastic wraps from previ-
ous studies (7.6 cm wide). The authors observed that the
elastic consistently resulted in complete vein occlusion
when it was tightened on the thigh based on the percep-
tual response of 7 (moderate pressure without pain) on
the tightness scale with 11 descriptors (0–10), but not in
the arteries. This way of applying elastic wraps according
to the response of a 7 out of 10 on the perceived tightness
scale has subsequently been used in several studies [20–
28]. However, applying the elastic wrap just for the per-
ception of tightness, seems to be a limited prescription
for pBFR, since there is no guarantee that the researcher
or trainer will equally restrict the elastic segment in all
training sessions.
Later studies tried to elucidate this concern. Bell et al.
[29] analyzed subjects’ levels of perceived tightness dur-
ing gradual inflation of a pneumatic cuff in the upper
and lower limbs. The pressures found were equivalent to
92% and 73% of the AOP for the upper and lower limbs,
respectively, when the subjects answered 7 on the per-
ceived tightness scale, and when they answered 10 on the
scale it was 126% and 106% of the AOP for the upper and
lower limbs, respectively. It is worth noting that restric-
tive pressures above 80% of the AOP can be considered
high and in most cases are not recommended for BFR
training [30]. Using a similar protocol, Bell et  al. [31]
analyzed the reliability of applied pressure when asking
 Aniceto and da Silva Leandro Sports Medicine - Open (2022) 8:87
participants to rate a 7 out of 10, over 3 separate visits.
The findings reported that the perceived tightness scale
does not provide reliable estimates of relative pressures
over multiple visits. Additionally, Bell et al. [32] observed
that 5  min and 24  h after a conditioning protocol with
specific pressures, subjects were unable to accurately
estimate the applied pressures. Importantly, all three
studies [29, 31, 32] used pneumatic cuffs to measure the
reproducibility or validity of perceived tightness; how-
ever, pBFR training uses non-inflatable elastic wraps.
In this sense, our laboratory developed a method in
2016 [33] to prescribe the pressure exerted by the elas-
tic based on the circumference of the upper and lower
limbs, which, according to previous studies, seems to be
the greatest predictor for determining the AOP [34–36].
According to procedures described and illustrated by
Aniceto [33] and Aniceto et al. [37], an elastic knee wrap
7.6  cm wide and 94  cm long (Harbinger Red-Line, Fair-
field, CA, USA) was adapted by placing 5  cm of Velcro
on the ends at the front and back, thereby enabling better
fixation on the limbs. In turn, with the purpose of finding
a circumference percentage which reflected a perceived
tightness of 7 (moderate pressure without pain) on the
scale proposed by Wilson et al. [19], circumference meas-
urements of the upper and lower limbs were performed
at rest at different times, and then the elastic wrap was
applied using the same circumference of the segment
(arm or thigh) for 30 s in order to familiarize the subject
with the perception equivalent to a rating of 0 (no pres-
sure; low anchorage); then, after 1  min the elastic was
stretched to the maximum on the limb for 30 s so that the
subject could experience a rating of 10 (intense pressure
with pain; high anchorage).
Taking as a reference the circumference of the arm and
thigh (100%), the subjects were then randomly assigned
to four pBFR conditions (15%, 20%, 25% and 30%) and
answered a number on the scale which represented the
perceived tightness. For example, a subject with an arm
circumference of 30  cm in the 20% pBFR condition had
the elastic marked with adhesive tape at 24 cm and this
6  cm restriction was applied to the arm; thus, the elas-
tic was stretched up to 24 cm in the arm with a circum-
ference of 30  cm. Our data showed that most subjects
responded 6 to 7 on the scale when they had the elastic
restriction at 25% of the circumference for the upper limb
and 30% for the lower limb. The reliability coefficients
(ICC) for these tightness perception measures were 0.74
(P = 0.014) for the arm and 0.86 (P = 0.001) for the thigh.
Unlike the previously reported techniques, in 2017,
Behringer et  al. [38] introduced a technique based on
the elasticity of the elastic wrap. They pulled the wraps
(13-cm wide) maximally (100% stretch) around the par-
ticipants’ thighs and marked them at each quarter of
Page 3 of 7
every winding. Then, the wraps were removed and reap-
plied with 75% of their maximum stretch. The authors
justified using this technique because they observed
that the length remained fairly constant after initially
stretching the elastic wraps, so they decided to stretch
the knee wraps before their first use to reduce the effect
of material slackening at later time points of the study.
The authors additionally used an ultrasound system to
ensure that the arterial blood flow was not occluded
at this pressure. This technique was later used in a few
studies [39, 40]. Despite the precautions used by the
authors, this technique has some limitations. The com-
position and mechanical properties of the elastic affect
how much the elastic can be stretched, so in some cases
with stiffer elastics this technique may be inappropri-
ate. In addition, several researchers may apply different
force when stretching the elastic, and thus achieve dif-
ferent lengths of elastic stretching. These issues make
it difficult to apply the technique and compare studies.
In 2018, Abe et  al. [41] used a similar procedure to
our laboratory in relation to the pBFR pressure pre-
scription based on the limb circumference, and dem-
onstrated that the brachial arterial blood flow was not
different between the elastic wrap (5-cm wide; custom
built (no manufacturer)) and nylon pneumatic cuff
(5-cm width; 60  cm length; SC5 Hokanson, Belleview,
WA, USA), respectively, when subjects were assessed
for low pressure BFR (10% of the arm circumference vs.
40% of AOP) and high pressures (20% of the arm cir-
cumference vs. 80% of the AOP). The results indicate
that an elastic wrap pulled to 10% and 20% of its arm
circumference decreases brachial artery blood flow in a
pressure-dependent manner. These data reinforce that
prescribing the pressure exerted by the elastic for pBFR
training based on the circumference of the limbs seems
to be a valid and effective prescription.
Another major issue related to pBFR prescription, and
which influences the pressure percentage is related to the
elastic’s material composition and architecture. We use
25% and 30% elastic restraint percentages in our labora-
tory [33, 37, 42], while other laboratories use 10% and
20% [41], and 15% [18], based on the circumference of
the limb at rest. This difference is related to the elastics
used; the elastic knee wrap (Harbinger Red-Line, Fair-
field, CA, USA; 7.6 cm width) used in our laboratory [33,
37, 42] and in various studies [8–10, 13, 19] consists of a
single layer of elastic rubber, making it possible to stretch
the elastic to 35% of the initial length in a practical way.
On the other hand, the elastic wrap (Custom Built (No
Manufacturer); 5  cm width) used in the study by Abe
et  al. [41] consists of three layers of elastic rubber with
a practical possibility of stretching up to approximately
30% of the initial length.
Aniceto and da Silva Leandro Sports Medicine - Open (2022) 8:87
The material organization and general structure of the
elastic wraps determine its ability to resist deformation.
In this sense, according to Hamill et  al. [43] a stress–
strain analysis can be performed to verify how a material
changes over time, how it reacts to different force appli-
cations and the absence of daily stress application. In this
perspective, according to a thesis published by Gomes
[44], the resistance of two elastic knee wraps (hard vs.
soft—Maba Murphy Confecções Ltda, Brazil) was tested
with the same composition (70% polyester and 30% elas-
todiene) and the same dimensions (2  m long and 8  cm
wide); however, through digital photographs he observed
that the hard elastic knee wrap presents twofold smaller
spacing between wefts than the soft elastic knee wrap,
and therefore the hard elastic presented 42.3% more
elasticity compared to the soft due to these structural
characteristics. On the other hand, the soft elastic wrap
endured 41.15% more deformation than the hard elastic
wrap when reaching the maximum elasticity point before
rupture. The author concluded that the spacing between
wefts was decisive for the elastic bands to present differ-
ences in the flow point (end of the elastic zone and begin-
ning of the plastic zone) and in the breaking point, and
the polyester was responsible for the maximum tension
limit of the analyzed elastic knee wraps.
In this stress–strain analysis perspective, Abe et  al.
[41] simply and practically reported a calibration proce-
dure for the elastic. The authors vertically fixed one end
of the elastic on the wall and placed a load (tension) at
the other end to observe the elastic deformation assum-
ing that there is a linear relationship between stress
and deformation in this type of material. Thus, it was
observed that the elastic stretched 2.7% of the initial
length for each 1 kg of load, maintaining this linear ratio
until it stretched to around 25%. Accordingly, it is sug-
gested that this type of procedure is performed before
training sessions to observe the wear of the elastic wrap.
In addition, it is recommended that the elastic length is
measured before and after the load is removed in order
to verify the mechanical elasticity property of the elas-
tic wrap. With these measures it is possible to check the
extensibility and elasticity properties of the elastic wrap
and thus make the decision to change it or create a cor-
rection factor.
The researchers in these studies carry out repro-
ducibility measures, report the calibration procedure
results, as well as (if possible) present the composition
and mechanical properties/characteristics of the elastic
wrap structure (i.e., elasticity coefficient) [45] in order to
enable better comparison between studies and reproduce
results. Additionally, in a training program that uses mul-
tiple exercise sessions, it is suggested after the measure-
ment of the limb circumference, that a transverse mark
Page 4 of 7
is made on the limb with a permanent marker to delimit
the height of the elastic wrap (upper edge), in this way,
maximize the reproducibility of elastic application. After
applying the elastic wrap on the proximal portion of the
limb, it is essential to check that the arterial blood flow
is not occluded. The portable vascular Doppler can be
used with the probe placed in the brachial or tibial artery.
This verification must be carried out in the three posi-
tions: supine, sitting and standing, given the differences
between the positions in relation to AOP [46].
Safety
Few studies in the literature have been concerned with
analyzing variables which could verify the safety of pBFR
training [30, 47]. In analyzing muscle damage, Wilson
et  al. [19] demonstrated that soreness, power and mus-
cle swelling were similar between low-load resistance
exercise with and without pBFR; in addition, Behringer
et al. [38] demonstrated that after 6 weeks of sprint train-
ing, the heart-type fatty acid-binding protein (h-FABP)
was significantly lower in the group that trained with
pBFR than in the control group, with similar responses
between groups regarding cortisol. Additionally, studies
have found similar acute pain responses between low-
load resistance exercise with and without pBFR [26, 40];
furthermore, the high-load resistance exercise induces
greater pain scores than low-load resistance exercise with
pBFR [26]. Considering cardiovascular events, studies
have compared high-load resistance exercise with low-
load resistance exercise with pBFR, noting that post-
exercise acute responses are similar between the exercise
protocols, in relation to autonomic modulation [25], as
well as on arterial stiffness and brachial systolic or dias-
tolic blood pressure [24].
These findings lead us to think that pBFR train-
ing in healthy individuals is safe, and it seems that side
effects or adverse events are minimal, with risks being
minimized when the practitioner or researcher is well
trained using appropriate methods in applying the elas-
tic wrap or cuff. According to Brandner et al. [47], most
often the side effects caused by traditional BFR training
seem to be associated with high pressure applied by the
cuff (~ 200 mmHg) or when thin cuffs (~ 3 cm) are used.
Previous studies have reported that wider cuffs require a
lower pressure to occlude blood flow compared with nar-
rower cuffs [34, 36, 48, 49]. Additionally, higher systolic
and diastolic blood pressures have been reported when
using narrower cuffs in comparison with wider cuffs [50].
Based on this information, we believe the concerns are
the same with pBFR training, meaning that high pres-
sures and thin elastic bands should be avoided. How-
ever, some possible contraindications of pBFR training
should be taken into consideration, such as venous
 Aniceto and da Silva Leandro Sports Medicine - Open (2022) 8:87
thromboembolism, peripheral vascular disease, unsta-
ble hypertension and pregnancy [51]. In this sense, the
scoring system proposed by Nakajima et  al. [51] or the
clinical screening tool proposed by Kacin et al. [52] assist
in tracking risk factors; thus, both tools can be used to
assess whether the individual has any contraindication to
perform pBFR training. In addition, it is recommended
to check the ankle brachial index (0.90 ≤ ABI ≤ 1.40) as it
is a predictor of cardiovascular disease, and most studies
with pBFR do not perform this measurement.
Conclusion and Perspectives
The literature demonstrates that in most cases the elas-
tic wrap can replace the pneumatic cuff traditionally used
for BFR training. Moreover, it is possible to apply dif-
ferent pressures with the elastic wrap to the individual,
making it possible to perform pressure progression in
the pBFR training over time. In summary, five techniques
were found chronologically to apply the elastic wrap dur-
ing pBFR training: (i) application-based technique by the
same investigator to maximize intra-rater reliability; (ii)
absolute overlap of the elastic tightened to a fixed value
(for example, 5.08 cm, 7.60 cm) of the initial application
without tension; (iii) according to the perceived tight-
ness scale; (iv) relative overlap of the elastic, in which it
was stretched to the maximum (100%) in the segment,
removed and then reapplied with 75% of the maximum
stretch; and (v) relative overlap of the elastic based on
the circumference of the limbs. Advantages and dis-
advantages can be observed given the evolution of the
techniques used in the studies since 2009, but several
studies have shown that limb circumference seems to be
the greatest predictor of AOP. Therefore, we reinforce
that applying the pressure exerted by the elastic for pBFR
training based on the circumference of the limbs is an
excellent, valid and safe technique.
In this perspective, it is suggested to use 10–30% elas-
tic restraint percentages based on the limb circumference
at rest for pBFR training, depending on the type of elas-
tic, experience and training objective, and also thinking
about the individual’s safety and adherence to the train-
ing program. Regarding the width of the elastic wrap,
we recommend using 5 to 10 cm in width for upper and
lower limbs. It is worth reinforcing the need for elastic
calibration before exercise sessions, especially in chronic
studies. However, future studies should be conducted
with pBFR combined with exercise using different elastic
wraps in terms of material composition and architecture,
as well as applying this type of training to healthy (i.e.,
athletes) and clinical populations (i.e., obese, injured).
Page 5 of 7
Abbreviations
BFR: Blood flow restriction; AOP: Arterial occlusion pressure; pBFR: Practical
blood flow restriction; h-FABP: Heart-type fatty acid-binding protein; ABI: Ankle
brachial index.
Acknowledgements
Not applicable.
Author Contributions
Both authors (RRA and LSL) have contributed significantly to this opinion
article. Both authors read and approved the final manuscript.
Funding
No sources of funding were used to assist in the preparation of this article.
Availability of Data and Materials
Not applicable.
Declarations
Ethics Approval and Consent to Participate
Not applicable.
Consent for Publication
Not applicable.
Competing Interests
Rodrigo Ramalho Aniceto and Leonardo da Silva Leandro declare that they
have no conflicts of interest relevant to the content of this article.
Received: 14 October 2021 Accepted: 8 June 2022
References
1. Batista MM, Silva DSG, Bento PCB. Effects of blood flow restriction train-
ing on strength, muscle mass and physical function in older individu-
als—systematic review and meta-analysis. Phys Occup Ther Geriatr.
2020;38(4):400–17. https://​doi.​org/​10.​1080/​02703​181.​2020.​17697​96.
2. Wortman RJ, Brown SM, Savage-Elliott I, Finley ZJ, Mulcahey MK. Blood
flow restriction training for athletes: a systematic review. Am J Sports
Med. 2021;49(7):1938–44. https://​doi.​org/​10.​1177/​03635​46520​964454.
3. Dos Santos LP, Santo RCE, Ramis TR, Portes JKS, Chakr RMS, Xavier RM.
The effects of resistance training with blood flow restriction on muscle
strength, muscle hypertrophy and functionality in patients with osteoar-
thritis and rheumatoid arthritis: a systematic review with meta-analysis.
PLoS ONE. 2021;16(11):e0259574. https://​doi.​org/​10.​1371/​journ​al.​pone.​
02595​74.
4. Abe T, Kearns CF, Sato Y. Muscle size and strength are increased following
walk training with restricted venous blood flow from the leg muscle,
Kaatsu-walk training. J Appl Physiol. 2006;100(5):1460–6. https://​doi.​org/​
10.​1152/​jappl​physi​ol.​01267.​2005.
5. Shinohara M, Kouzaki M, Yoshihisa T, Fukunaga T. Efficacy of tourniquet
ischemia for strength training with low resistance. Eur J Appl Physiol.
1997;77:189–91. https://​doi.​org/​10.​1007/​s0042​10050​319.
6. Gualano B, Ugrinowitsch C, Neves M Jr, Lima FR, Pinto AL, Laurentino
G, et al. Vascular occlusion training for inclusion body myositis: a novel
therapeutic approach. J Vis Exp. 2010;40:e1894. https://​doi.​org/​10.​3791/​
1894.
7. Loenneke JP, Pujol TJ. The use of occlusion training to produce muscle
hypertrophy. Strength Cond J. 2009;31(3):77–84. https://​doi.​org/​10.​1519/​
SSC.​0b013​e3181​a5a352.
8. Loenneke JP, Balapur A, Thrower AD, Barnes JT, Pujol TJ. The perceptual
responses to occluded exercise. Int J Sports Med. 2011;32(3):181–4.
https://​doi.​org/​10.​1055/s-​0030-​12684​72.
9. Loenneke JP, Kearney ML, Thrower AD, Collins S, Pujol TJ. The acute
response of practical occlusion in the knee extensors. J Strength Cond
Res. 2010;24(10):2831–4. https://​doi.​org/​10.​1519/​JSC.​0b013​e3181​f0ac3a.
Aniceto and da Silva Leandro Sports Medicine - Open (2022) 8:87
10. Loenneke JP, Thrower AD, Balapur A, Barnes JT, Pujol TJ. Blood flow-
restricted walking does not result in an accumulation of metabolites. Clin
Physiol Funct Imaging. 2012;32(1):80–2. https://​doi.​org/​10.​1111/j.​1475-​
097X.​2011.​01059.x.
11. Loenneke JP, Thrower AD, Balapur A, Barnes JT, Pujol TJ. The energy
requirement of walking with restricted blood flow. Sport Sci.
2011;4(2):7–11.
12. Loenneke JP, Wilson JM, Balapur A, Thrower AD, Barnes JT, Pujol TJ. Time
under tension decreased with blood flow-restricted exercise. Clin Physiol
Funct Imaging. 2012;32(4):268–73. https://​doi.​org/​10.​1111/j.​1475-​097X.​
2012.​01121.x.
13. Loenneke JP, Young KC, Wilson JM, Andersen JC. Rehabilitation of an oste-
ochondral fracture using blood flow restricted exercise: a case review. J
Bodyw Mov. 2013;17(1):42–5. https://​doi.​org/​10.​1016/j.​jbmt.​2012.​04.​006.
14. Loenneke JP, Balapur A, Thrower AD, Barnes J, Pujol TJ. Blood flow restric-
tion reduces time to muscular failure. Eur J Sport Sci. 2012;12(3):238–43.
https://​doi.​org/​10.​1080/​17461​391.​2010.​551420.
15. Yamanaka T, Farley RS, Caputo JL. Occlusion training increases
muscular strength in division IA football players. J Strength Cond Res.
2012;26(9):2523–9. https://​doi.​org/​10.​1519/​JSC.​0b013​e3182​3f2b0e.
16. Luebbers PE, Fry AC, Kriley LM, Butler MS. The effects of a 7-week practi-
cal blood flow restriction program on well-trained collegiate athletes.
J Strength Cond Res. 2014;28(8):2270–80. https://​doi.​org/​10.​1519/​JSC.​
00000​00000​000385.
17. Luebbers PE, Witte EV, Oshel JQ, Butler MS. Effects of practical blood
flow restriction training on adolescent lower-body strength. J Strength
Cond Res. 2019;33(10):2674–83. https://​doi.​org/​10.​1519/​JSC.​00000​00000​
002302.
18. Thiebaud RS, Abe T, Loenneke JP, Garcia T, Shirazi Y, McArthur R. Acute
muscular responses to practical low-load blood flow restriction exercise
versus traditional low-load blood flow restriction and high-/low-load
exercise. J Sport Rehabil. 2019;29(7):984–92. https://​doi.​org/​10.​1123/​jsr.​
2019-​0217.
19. Wilson JM, Lowery RP, Joy JM, Loenneke JP, Naimo MA. Practical blood
flow restriction training increases acute determinants of hypertrophy
without increasing indices of muscle damage. J Strength Cond Res.
2013;27(11):3068–75. https://​doi.​org/​10.​1519/​JSC.​0b013​e3182​8a1ffa.
20. Lowery RP, Joy JM, Loenneke JP, de Souza EO, Machado M, Dudeck JE,
et al. Practical blood flow restriction training increases muscle hyper-
trophy during a periodized resistance training programme. Clin Physiol
Funct Imaging. 2014;34(4):317–21. https://​doi.​org/​10.​1111/​cpf.​12099.
21. Head P, Austen B, Browne D, Campkin T, Barcellona M. Effect of practical
blood flow restriction training during bodyweight exercise on muscular
strength, hypertrophy and function in adults: a randomised controlled
trial. Int J Ther Rehabil. 2015;22(6):263–71. https://​doi.​org/​10.​12968/​ijtr.​
2015.​22.6.​263.
22. Paton CD, Addis SM, Taylor LA. The effects of muscle blood flow restric-
tion during running training on measures of aerobic capacity and run
time to exhaustion. Eur J Appl Physiol. 2017;117:2579–85. https://​doi.​org/​
10.​1007/​s00421-​017-​3745-3.
23. Scott BR, Peiffer JJ, Goods PSR. The effects of supplementary low-load
blood flow restriction training on morphological and performance-based
adaptations in team sport athletes. J Strength Cond Res. 2017;31(8):2147–
54. https://​doi.​org/​10.​1519/​JSC.​00000​00000​001671.
24. Tai YL, Marshall EM, Glasgow A, Parks JC, Sensibello L, Kingsley JD. Pulse
wave reflection responses to bench press with and without practical
blood flow restriction. Appl Physiol Nutr Metab. 2018;44(4):341–7. https://​
doi.​org/​10.​1139/​apnm-​2018-​0265.
25. Tai YL, Marshall EM, Glasgow A, Parks JC, Sensibello L, Kingsley JD.
Autonomic modulation following an acute bout of bench press with and
without blood flow restriction. Eur J Appl Physiol. 2019;119(10):2177–83.
https://​doi.​org/​10.​1007/​s00421-​019-​04201-x.
26. Miller RM, Galletti BAR, Koziol KJ, Freitas EDS, Heishman AD, Black CD,
et al. Perceptual responses: clinical versus practical blood flow restriction
resistance exercise. Physiol Behav. 2020;227:113137. https://​doi.​org/​10.​
1016/j.​physb​eh.​2020.​113137.
27. Freitas EDS, Galletti BRA, Koziol KJ, Miller RM, Heishman AD, Black CD,
et al. The acute physiological responses to traditional versus practical
blood flow restriction resistance exercise in untrained men and women.
Front Physiol. 2020;11:577224. https://​doi.​org/​10.​3389/​fphys.​2020.​577224.
Page 6 of 7
28. Fortin JF, Billaut F. Blood-flow restricted warm-up alters muscle hemo-
dynamics and oxygenation during repeated sprints in american football
players. Sports (Basel). 2019;7(5):121. https://​doi.​org/​10.​3390/​sport​s7050​
121.
29. Bell ZW, Dankel SJ, Mattocks KT, Buckner SL, Jessee MB, Mouser JG, et al.
An investigation into setting the blood flow restriction pressure based
on perception of tightness. Physiol Meas. 2018;39(10):105006. https://​doi.​
org/​10.​1088/​1361-​6579/​aae140.
30. Patterson SD, Hughes L, Warmington S, Burr J, Scott BR, Owens J, et al.
Blood flow restriction exercise: considerations of methodology, applica-
tion, and safety. Front Physiol. 2019;10:533. https://​doi.​org/​10.​3389/​fphys.​
2019.​00533.
31. Bell ZW, Dankel SJ, Spitz RW, Chatakondi RN, Abe T, Loenneke JP. The per-
ceived tightness scale does not provide reliable estimates of blood flow
restriction pressure. J Sport Rehabil. 2020;29(4):516–8. https://​doi.​org/​10.​
1123/​jsr.​2018-​0439.
32. Bell ZW, Spitz RW, Wong V, Yamada Y, Chatakondi RN, Abe T, et al. Condi-
tioning participants to a relative pressure: implications for practical blood
flow restriction. Physiol Meas. 2020;41(8):08nt01. https://​doi.​org/​10.​1088/​
1361-​6579/​aba810.
33. Aniceto RR. Escalas de percepção subjetiva de recuperação (CR10-RIS)
e de esforço (OMNI-RES): uma validação concorrente para exercícios de
força com e sem restrição de fluxo sanguíneo. Doctoral dissertation. João
Pessoa: Universidade Federal da Paraíba; 2016.
34. Jessee MB, Buckner SL, Dankel SJ, Counts BR, Abe T, Loenneke JP. The
influence of cuff width, sex, and race on arterial occlusion: implications
for blood flow restriction research. Sports Med. 2016;46(6):913–21.
https://​doi.​org/​10.​1007/​s40279-​016-​0473-5.
35. Loenneke JP, Allen KM, Mouser JG, Thiebaud RS, Kim D, Abe T, et al. Blood
flow restriction in the upper and lower limbs is predicted by limb circum-
ference and systolic blood pressure. Eur J Appl Physiol. 2015;115(2):397–
405. https://​doi.​org/​10.​1007/​s00421-​014-​3030-7.
36. Loenneke JP, Fahs CA, Rossow LM, Sherk VD, Thiebaud RS, Abe T, et al.
Effects of cuff width on arterial occlusion: implications for blood flow
restricted exercise. Eur J Appl Physiol. 2012;112(8):2903–12. https://​doi.​
org/​10.​1007/​s00421-​011-​2266-8.
37. Aniceto RR, Robertson RJ, Silva AS, Costa PB, Araújo LC, Silva JCG, et al. Is
rating of perceived exertion a valid method to monitor intensity during
blood flow restriction exercise? Hum Mov. 2021;22(2):68–77. https://​doi.​
org/​10.​5114/​hm.​2021.​100015.
38. Behringer M, Behlau D, Montag JCK, McCourt ML, Mester J. Low-intensity
sprint training with blood flow restriction improves 100-m dash. J
Strength Cond Res. 2017;31(9):2462–72. https://​doi.​org/​10.​1519/​JSC.​
00000​00000​001746.
39. Held S, Behringer M, Donath L. Low intensity rowing with blood flow
restriction over 5 weeks increases V̇O2max in elite rowers: a randomized
controlled trial. J Sci Med Sport. 2020;23(3):304–8. https://​doi.​org/​10.​
1016/j.​jsams.​2019.​10.​002.
40. Gavanda S, Isenmann E, Schlöder Y, Roth R, Freiwald J, Schiffer T,
et al. Low-intensity blood flow restriction calf muscle training leads
to similar functional and structural adaptations than conventional
low-load strength training: a randomized controlled trial. PLoS ONE.
2020;15(6):e0235377. https://​doi.​org/​10.​1371/​journ​al.​pone.​02353​77.
41. Abe T, Mouser JG, Dankel SJ, Bell ZW, Buckner SL, Mattocks KT, et al. A
method to standardize the blood flow restriction pressure by an elastic
cuff. Scand J Med Sci Sports. 2019;29(3):329–35. https://​doi.​org/​10.​1111/​
sms.​13340.
42. Galletti B, Batista F, Domingos-Gomes J, Freitas E, Pereira P, Batista G,
et al. Pressor responses to high and low-intensity continuous or interval
cycling with/without blood flow restriction. Med Sci Sports Exerc.
2017;49(5S):254. https://​doi.​org/​10.​1249/​01.​mss.​00005​17549.​89229.​be.
43. Hamill J, Knutzen K, Derrick TR. Biomechanical basis of human move-
ment. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2015.
44. Gomes WA. Efeito da utilização da banda elástica de joelho no sinergismo
muscular e na mecânica do agachamento em sujeitos treinados. Master
of Science thesis. Piracicaba: Universidade Metodista de Piracicaba; 2014.
45. Freitas FSD, Gomes WA, Marchetti PH. Effects of elastic wrap on muscle
activity and isometric force of knee extensors. Rev Bras Med Esporte.
2018;24(4):295–9. https://​doi.​org/​10.​1590/​1517-​86922​01824​04166​615.
46. Neto GR, Silva JC, Umbelino RK, Silva HG, Neto EA, Oliota-Ribeiro LS, et al.
Are there differences in auscultatory pulse in total blood flow restriction
 Aniceto and da Silva Leandro Sports Medicine - Open (2022) 8:87 Page 7 of 7

between positions, limbs and body segments? Rev Bras Cineantropom

Desempenho Hum. 2018;20(5):381–90. https://​doi.​org/​10.​5007/​1980-​
0037.​2018v​20n5p​381.
47. Brandner CR, May AK, Clarkson MJ, Warmington SA. Reported side-effects
and safety considerations for the use of blood flow restriction during
exercise in practice and research. Tech Orthop. 2018;33(2):114–21. https://​
doi.​org/​10.​1097/​BTO.​00000​00000​000259.
48. Dankel SJ, Buckner SL, Counts BR, Jessee MB, Mouser JG, Mattocks KT,
et al. The acute muscular response to two distinct blood flow restriction
protocols. Physiol Meas. 2017;104(1):64–76. https://​doi.​org/​10.​1556/​2060.​
104.​2017.1.1.
49. Crenshaw AG, Hargens AR, Gershuni DH, Rydevik B. Wide tourniquet
cuffs more effective at lower inflation pressures. Acta Orthop Scand.
1988;59(4):447–51. https://​doi.​org/​10.​3109/​17453​67880​91494​01.
50. Mouser JG, Dankel SJ, Jessee MB, Mattocks KT, Buckner SL, Counts BR,
et al. A tale of three cuffs: the hemodynamics of blood flow restric-
tion. Eur J Appl Physiol. 2017;117(7):1493–9. https://​doi.​org/​10.​1007/​
s00421-​017-​3644-7.
51. Nakajima T, Morita T, Sato Y. Key considerations when conducting
KAATSU training. Int J KAATSU Training Res. 2011;7(1):1–6. https://​doi.​org/​
10.​3806/​ijktr.7.1.
52. Kacin A, Rosenblatt B, Žargi TG, Biswas A. Safety considerations with
blood flow restricted resistance training. Ann Kinesiol. 2015;6(1):3–26.

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